Provider Demographics
NPI:1851325260
Name:MOORE, KENT E (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 RANDOLPH RD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-2034
Mailing Address - Country:US
Mailing Address - Phone:704-358-8898
Mailing Address - Fax:704-358-8889
Practice Address - Street 1:2711 RANDOLPH RD
Practice Address - Street 2:SUITE 510
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2034
Practice Address - Country:US
Practice Address - Phone:704-358-8898
Practice Address - Fax:704-358-8889
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53661223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2415095Medicare ID - Type Unspecified
NCU02206Medicare UPIN